Preoperative bone health assessment and optimization in spine surgery

Abstract

OBJECTIVEThe purpose of this investigation was to characterize the bone health in preoperative spine surgery patients. This information will provide a framework to understand the needs and methods for providing bone health optimization in elective spine surgery patients.METHODSA retrospective study of 104 patients undergoing bone health optimization was performed. Patients were selected based on risk factors identified by the surgeon and suspected compromised bone health. Evaluation included history and examination, laboratory investigations, and bone mineral density (BMD) at 3 sites (femoral neck, lumbar spine, and radius). Patients’ bone status was classified using WHO criteria and expanded criteria recommended by the National Osteoporosis Foundation (NOF). The 10-year Fracture Risk Assessment Tool (FRAX) scores of the hip and major osteoporotic fracture (MOF) were calculated with and without femoral neck BMD, with spine BMD, and with the trabecular bone score (TBS). Antiresorptive and anabolic agents were provided in accordance with meeting NOF criteria for treatment of osteoporosis.RESULTSThe mean patient age was 69.0 years, and 81% of patients were female. The mean historical height loss was 5.6 cm, and 54% of patients had a history of fracture. Secondary osteoporosis due to chronic renal failure, inflammatory arthritis, diabetes, and steroid use was common (51%). The mean 25-hydroxy vitamin D was 42.4 ng/ml and was normal in 81% of patients, with only 4 patients being deficient. The mean T-scores were −2.09 (SD 0.71) of the femoral neck, −0.54 (1.71) of the lumbar spine, and −1.65 (1.38) of the distal radius. These were significantly different. The 10-year FRAX MOF score was 20.7%, and that for hip fracture was 6.9% using the femoral neck BMD and was not significantly different without the use of BMD. The FRAX risk-adjusted score using the lumbar spine BMD and TBS was significantly lower than that for the hip. Osteoporosis was present in 32.1% according to WHO criteria compared with 81.6% according to NOF criteria. Antiresorptive medications were recommended in 31 patients and anabolic medications in 44 patients.CONCLUSIONSSurgeons can reliably identify patients with poor bone health by using simple criteria, including historical height loss, history of fracture, comorbidities associated with osteoporosis, analysis of available imaging, and calculation of FRAX score without BMD. High-risk patients should have BMD testing and bone health assessment. In patients with osteoporosis, a comprehensive preoperative bone health assessment is recommended and, if warranted, pharmacological treatment should be started.

Adverse Effect of Preoperative Steroid Use on Surgical Outcomes

“…have used preoperative corticosteroids [10]. These depictions (4.61%, 95% confidence interval [CI], 4.36 -4.86) of the population was on preoperative steroids, and 1469 (5.52%; 95% CI, 5.24 -5.79) were followed by postoperative complications [11].…”

Bone Health Optimization (BHO) in Spine Surgery

“…4 A major limitation in spine surgery patients is that arthritis and degenerative scoliosis increase DXA-measured BMD. Anderson et al 6 reported that the spine T-scores were 1.5 × higher than the hip in spine patients. Another limitation of DXA is that the T-score criteria has low sensitivity as the majority of patients having low-energy fractures have T-scores > −2.5.…”

Preoperative Optimization for Adult Spinal Deformity Surgery

“…11,12 Previous literature has demonstrated rates of osteoporosis in ASD as high as 32.8%, with only 34.4% of those patients receiving treatment. 12,13 Osteoporosis is a well-established risk factor for complications after spinal fusion, including proximal junctional kyphosis, pseudoarthrosis, fracture, and revision surgery. [14][15][16][17] Given the high rate of osteoporosis in ASD patients, the criteria for screening for osteoporosis have been challenging and expanded to increase sensitivity.…”